PROGRESS OF MEDICINE.

MEDICINE.

The Spirochete and the Treatment of Syphilis.

J. F. Breakey, Ann Arbor, Mich. (Journal A. M. A., December 12), finds a partial answer to the question: What advantage is the discovery of the spirochete to the treatment of syphilis in the recent work of Metchnikoff showing the prophylactic value of calomel ointment inunctions and atoxyl. If further work demonstrates the truth of the claims of the French investigators as to the prophylactic power of atoxyl, given soon after inoculation, such a fact can be made of practical use in one way, at least. If all persons who have been exposed to a possible syphilitic infection were to submit themselves for treatment by prophylactic doses of atoxyl, it would be possible to wipe out the disease. The treatment would have to be instituted, however, before the infection had been generally disseminated and before the finding of the spirochete. In general practice, therefore, all suspicious cases would have to be treated alike, but the treatment with the proper dose of atoxyl is harmless. In case of the established disease, the only change in treatment which could be wrought by the discovery of the infecting organism would be to cause an earlier beginning of constitutional treatment, and this would still be open to the objection of possibly causing an early disappearance of symptoms and the production of a false sense of security, leading the patient to abandon the treatment too soon. Breakey quotes, with approval, the conclusions of Paul Salmon (Ann. de l'Inst. Pasteur, January, 1908), that arsenic is as much a specific as mercury in syphilis, and more reliable as an abortive. As a remedy it is preferable in all stages, and is of special value in the graver and more malignant forms of the disease. It is not contraindicated in the parasyphilitic manifestations, but even ameliorates many symptoms. Syphilis may be aborted by atoxyl administered as late as from one to two weeks after inoculation. Small doses are ineffective and useless and too large ones cause toxic symptoms. The ordinary dose should be 50 centigrams, which should be given hypodermically at intervals of one or two days and repeated from

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four to eight or ten times, after which an interval of rest should be taken, or the treatment continued with mercury or iodin. Good results have been observed from the alternation

of these remedies, or even their combined use. 4T

Digitalis in Pneumonia.85 L

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T. F. Reilly, New York (Journal A. M. A., December 26), believes in the use of fairly large doses of digitalis in the treatment of pneumonia. In this disease, he says, there are two general indications from start to finish: 1. To get rid of the toxins, so far as possible, until nature is able to furnish her antitoxin. 2. To sustain the heart and circulation, on which the brunt of the attack falls, until the danger is past. The toxins must be eliminated if possible, by the bowels, skin and kidneys, and in digitalis, with proper, dosage and manipulation, we have one of the best diuretics. It acts on the heart by lengthening the diastole, and so rests the wearied and weakened heart muscle, and, beyond this, it also aids in the direct nutrition of the heart, the blood supply reaching it only through the period of diastole.. While he does not hold that all pneumonia patients can be saved by this drug, he claims that we can frequently keep the pulse below 100 by its use, and the elaborate statistics of the Massachusetts General Hospital show that with the pulse under 100 the disease is seldom or never fatal. It is too late to give digitalis when the heart begins to fail, for it requires from thirty to forty hours for it to get a complete hold on the heart. As to the dangers of digitalis medication, aside from a marked arrhyrthmia after the crisis, which is often characteristic of the disease itself, he has seen no evil effects from its use. The symptoms of digitalis intoxication, if they appear, are not usually alarming and can be easily overcome by lessening the dose. His statistics of his private practice include 126 cases of lobar pneumonia and 24 of bronchopneumonia. There, were four deaths in each series, a percentage of 3.17 for the lobar variety and 16.6 for the other. The bronchopneumonia deaths were three of them at three years of age, and one (tuberculous) at 75; in all the deaths from lobar pneumonia the patients were past 40, the serious period for the disease. The treatment was uniformly the administration of rather large doses of a reliable

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preparation of digitalis, usually the fluid extract, as soon as the diagnosis was made, with simple diaphoretics and diuretics for the elimination of toxins and the use of strychnin, caffein, etc., as stimulation was required.

Amebic Dysentery.

The necessity of surgical treatment for all cases of chronic amebic dysentery is insisted on by J. M. Holt, Brooklyn, N. Y. (Journal A. M. A., December 19), i. e., in all cases in which, after a fair trial of other treatment, the Ameba coli could still be found in the stools. All observers, he says, are agreed as to the tendency of the disease to resist treatment and to run on indefinitely, and we should not permit this when a simple surgical operation will clear up matters at once. There are altogether too many patients in the country going about uncured for years, and he asks: Has appendicostomy ever been proposed to them? While there may be a debatable ground for the adherents of the medical treatment of appendicitis, there is none in this case. A case, he holds, may be considered no longer acute and amenable to medical treatment after it has lasted nine months or a year. In his opinion, moreover, there is no known drug which, given by the mouth, can be tolerated in the upper digestive tract in sufficient strength to destroy the ameba in the colon. In conclusion, he suggests the possibility that the Ameba coli may not be equally pathogenic to all, as some do not contract the disease after exposure. The so-called Entameba coli may be the form of parasite found in the stools of individuals not thus susceptible. The so-called Entameba dysenteria may be the same parasite developing greater activity; coincident with morphologic changes in an individual having a susceptibility to the organism. He asks whether it has ever been found in a case presenting no clinical symptoms.

Tuberculosis Among the Jews.

Maurice Fishberg, New York (Medical Record, December 26, 1908), takes up the question of racial immunity of the Jews to tuberculosis. He considers that this immunity is not due to their habits of life or diet, as far as connected with the Jewish ceremonial, nor to the inheritance of pure Jewish blood, but to a kind of immunity arising from the fact that town dwellers Vol. 29-3

become less liable to tuberculosis after years and generations of residence in towns, which he thinks has been the case with the Jews for centuries. Examination of statistics from various countries shows that the Jew all over the world is less susceptible than other nations to tuberculosis, even when their conditions of life are the same with those around them. The Jews of New York are most of them garment workers, and their ancestors have been garment workers and dwellers in towns for generations. The same sort of immunity is thus acquired as is acquired by nations to other infectious diseases.

Functional Neuroses.

Speaking of the modern tendency to non-medical treatment of disease as shown in Eddyism, the so-called Emmanuel movement, etc., J. Collins, New York (Journal A. M. A., January 9), considers the medical profession to be, to some extent, responsible. He thinks that until recently the general practitioner has had little instruction in regard to disorders of the nervous system, and more especially the so-called functional diseases. He thinks that there is still a trace of the old idea of moral perversion in these cases- -a sort of relic of the old idea of demoniacal possession. The idea of reflex influence has also its part and still another reason is the fact that psychology is still an unknown department of knowledge to the majority of general practitioners. The average physician, moreover, is at a loss how to proceed with the necessary examination with these functional cases. He undertakes their treatment with a very indefinite diagnosis, if any. If medical students, he says, were given even an elementary course in psychology their attitude toward their patients and toward the psychic symptoms they present, not only in nervous diseases, but in many other diseases, would be different from what it frequently is. He takes up especially the Emmanuel movement, which is having such a vogue in certain quarters at the present time, and thinks that the clergymen engaged in it are going beyond their proper province and that they might more becomingly display some little measure of the quality displayed so prominently by the founder of our religion, viz., humility. He quotes from the utterances of Dr. Worcester and Bishop Fallows to show that they misunderstand the position of physicians on these subjects and, in fact, the

whole subject on which they claim to be experts, especially as regards the frequency of functional nervous diseases in modern times. Their claims of success, too, he considers very extravagant and their zeal not all according to knowledge. He says that if any one can believe they can cure 80 per cent. of cases of inebriety he would not wish to disturb his happiness by undeceiving him from his happy delusion, if it could be avoided.

Mosquito Destruction in the Tropics.

J. A. LePrince, Ancon, Canal Zone (Journal A. M. A., December 26), describes the conditions and methods of mosquito destruction in the Canal Zone. The malaria-bearing species of anopheles are all shade-loving, and, though they will bite at any time, there is no record of their biting in full sunlight. Whether in a shaded area they will bite malarial persons and remain there long enough to transmit it to other persons in the same place has not been settled, but seems possible. Some anopheles breed throughout the year on the Isthmus, and the larvæ have been taken in brackish water containing up to 90 per cent. of sea water. The difficulties of mosquito destruction. in the tropics, as compared with more northern latitudes, are enumerated. They are: 1. The continuous propagation throughout the year. 2. This is especially a difficulty during the dry season, when the streams become stagnant and alive with the larvæ. 3. The rapid growth of algae, etc., in the ditches, sheltering the larvæ and preventing their destruction by fish. 4. Owing to the great extent of drainage required on account of the heavy rainfall, it is impracticable to keep the waters free from such growth with the available labor. 5. The difficulty of finding all the breeding places in a climate where the rainfall is so great and the ground so saturated during a larger part of the year. 6. The necessity of keeping down the rapid growth of jungle which prevents evaporation and conceals breeding places of the mosquito. The methods used to destroy mosquitoes are: Fumigation, used for dwellings, cars, etc.; crude petroleum, which has not been very successful; larvacides, of which phinotas oil has been found one of the most efficient; open ditches, which are useful if shallow and quick to dry up after a rain; blind drains, used before the tile. drains were introduced; filling in of depressions and low